Percutaneous Tracheostomy Insertion Procedure Sample Report

DATE OF OPERATION:  MM/DD/YYYY

The post Percutaneous Tracheostomy Insertion Procedure Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

OBJECTIVE: The patient is a thin gentleman, in no distress. WT: 128. P: 116. BP: 118/66. RR: 20. Saturations on 1.5 liters 93%. HEENT: He has mild temporal wasting. Pupils are equal and reactive. Nares have no lesions or exudates. There is no dried heme. Oral cavity has no lesions or exudates. Neck: Supple. Cardiac: PMI is not appreciated. Regular, S1/S2. Lungs: He is hyperresonant to percussion. He has moderately diffusely decreased breath sounds with no wheezing or rales. Abdomen: Soft and nontender. Extremities: No edema.

ASSESSMENT: The patient has right upper lobe pneumonia with extensive smoking history and likely chronic obstructive pulmonary disease, shortness of breath, mild cough and hypoxemia.

PLAN: The patient needs a followup chest x-ray to make sure that the infiltrate has cleared. If not, he will need a CT scan. He needs a check of his overnight oximetry and a 6-minute walk on his O2 to assure adequacy of his O2 needs, and he needs PFTs. As we were leaving, his daughter complained of him having some epistaxis. We added humidity to his O2 and gave him saline nasal spray. Follow up after the aforementioned studies, and they understand and agree with the plan.

Pulmonary SOAP Note Medical Transcription Sample Report #2

SUBJECTIVE: The patient is here for a followup. She had her surgery on her shoulder and had it replaced again and is feeling pretty good. She is dyspneic with activity and talking too much. Other than that, she has no new complaints.

OBJECTIVE: WT: She has gained 8 pounds. P: 74. BP: 114/64. RR: 22. Saturations on 3 liters initially 86% and with rest 94%. HEENT: She has no lesions or exudates. Neck: Supple. Lungs: She has mildly decreased breath sounds with no wheezing or rales. Cardiac: Regular, S1/S2. Abdomen: Benign. Extremities: She has +1 ankle edema, and her scar on her right shoulder is healing well.

DIAGNOSTICS: Her chest x-ray from the hospital showed no acute cardiopulmonary disease. She does have COPD, and the right upper lobe infiltrate has resolved.

ASSESSMENT: She has chronic obstructive pulmonary disease with atrial fibrillation, congestive heart failure intermittently with dyspnea, hypoxemia, bronchiectasis, and she is status post shoulder replacement.

PLAN: We told her to follow up with Dr. Jane Doe. We will continue O2. We started her on Spiriva. We told her to hold off on her Atrovent to see how she does with that. We will see her back in 3 months. She knows to call if there is any change in her pulmonary symptoms.

Pulmonary SOAP Note Medical Transcription Sample Report #3

SUBJECTIVE: The patient is here for a followup of her PFTs. She continues to complain of excessive daytime somnolence and fatigue. She said she used to snore but is better on the oxygen therapy. Other than that, she has no new complaints of any kind. She does have achy legs at times.

OBJECTIVE: WT: She has gained a little bit of weight, up to 204 pounds from 198. P: 88. BP: 134/82. RR: 20. Saturations on room air 94%. HEENT: Unchanged from her prior visits. Neck: Supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign, but obese. Extremities: No edema.

DIAGNOSTICS: Her PFTs showed just a very mild decrease in her TLC and FVC from several years ago, and her overnight oximetry on 2 liters shows no significant desaturations.

ASSESSMENT: She has moderate pulmonary hypertension with vocal cord nodules and hoarseness, hiatal hernia, abnormal PFTs, chronic anemia, and known mild obstructive sleep apnea.

PLAN: I am going to recheck her polysomnography to see if there is anything else that could be contributing to her symptoms. If so, then we will intervene on that level. I am going to get a 6-minute walk. I will consider doing a followup CT scan after we recheck her lung volumes in 6 months and follow her a little more closely. She understands and agrees with the plan.

Pulmonary SOAP Note Medical Transcription Sample Report #4

SUBJECTIVE: The patient is here for a hospital followup. She is feeling pretty good. She was hospitalized for shortness of breath, cough and bronchospasm. She did well with inhaled bronchodilators and steroids and was discharged to home in several days. She has had similar episodes, which at times were produced by extreme stress. She took some Advair for a while and then took some Foradil. She has been off of everything for a couple of weeks, and she is feeling pretty good. She is still fatigued, but other than that, she is doing well.

OBJECTIVE: She looks okay. WT: 160. P: 74. BP: 132/70. RR: 18. Saturations on room air 97%. HEENT: She has no lesions or exudates. Neck: Supple without adenopathy. Lungs: Clear to A/P. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: She has mild asthma with exacerbation of allergic rhinitis, mostly manifesting as a horrific cough and some palpitations also contributing to things.

PLAN: At this point in time, we would like to check some PFTs to see if she needs to be on some type of maintenance therapy. We discussed the rationale of this with her. She understands and agrees, and we will see her back after those.

Pulmonary SOAP Note Medical Transcription Sample Report #5

SUBJECTIVE: The patient is here for a followup. She has found out she is diabetic, but other than that, she is doing well. She occasionally has cough and dyspnea on exertion, but she is doing okay. She has no new complaints at this time.

OBJECTIVE: She looks good. WT: 168. P: 100. BP: 146/76. RR: 18. Saturations on room air 94%. HEENT: Unchanged from her prior visit. Neck: Supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

DIAGNOSTICS: CT scan shows no changes.

ASSESSMENT: She is status post right upper lobectomy for lung carcinoma T2 versus T3N1M0 with hypoxemia, adenopathy that is unchanged, chronic obstructive pulmonary disease, and a new diagnosis of diabetes mellitus.

PLAN: We will see her back in 6 months, but we will get a CT scan in a year unless the medical oncologist or radiation oncologist would like it sooner.

Pulmonary SOAP Note Medical Transcription Sample Report #6

SUBJECTIVE: The patient is here for followup. He is tolerating the BiPAP. He did well on that. He is complaining of increasing shortness of breath, cough and productive phlegm. He has a little bit of an infiltrate on his chest x-ray. He has no other fevers, chills or sweats. He actually is feeling a little bit better.

OBJECTIVE: WT: 242. P: 62. BP: 128/64. RR: 24. Saturations on room air 93%. HEENT: He has no lesions or thrush. Neck is supple without adenopathy. Lungs: He has a few coarse rhonchi in the right lung. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: He has right upper lobe pneumonia with abnormal sputum, obstructive sleep apnea with RDI of around 25, history of tracheal stent, coronary artery disease, myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus and peripheral vascular disease.

PLAN: Today, we put him back on his inhaled tobramycin for 2 weeks, Levaquin 500 mg a day for 14 days. We will check a chest x-ray in 2-3 weeks. We will see him back then and then we will readdress his sleep issues, and he will need an overnight oximetry on the BiPAP.

Pulmonary SOAP Note Medical Transcription Sample Report #7

SUBJECTIVE: The patient is here at Dr. John Doe’s request. She has been coughing, short of breath since Friday. She said she got it flared up by someone’s perfume. She was better on Saturday. Today, she is worse again, took some Depo-Medrol 160 mg today. She is coughing. She has no productive phlegm. She has tightness in her chest, and she took some Vantin 200 mg twice a day for 4 days, doxycycline 200 mg twice a day. She was not put on any oral steroids. Her peak expiratory flow rates at home have been greater than 250.

OBJECTIVE: On examination today, she is coughing, dyspneic. WT: She is not weighed. P: 114. BP: Pending. RR: 22. Saturations on room air 97%. HEENT: She has no lesions or thrush. Neck is supple without adenopathy. Lungs: She has mildly decreased breath sounds with an expiratory wheeze. She is moving fairly good air. She has increased respiratory effort. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: She has status asthmaticus with cough, was secondary to her underlying asthma, allergic symptoms, and a prolonged QT. She just saw Dr. Jane Doe today and there is no concern with that.

PLAN: She needs the Vantin, which she will continue for 6 more days. She needs to go home. Her peak expiratory flow in the office was 400 pre-bronchodilator. She is taking a treatment right now. I gave her prednisone burst and taper. I will see her back next week. If her symptoms worsen or she does not improve, she needs to go to the emergency room. She understands that.

Pulmonary SOAP Note Medical Transcription Sample Report #8

SUBJECTIVE: The patient is here for followup. He has a little dyspnea on exertion. We checked his oxygen saturations on room air, and at rest, they are 85%, so he is on his O2. He has no new symptoms or increasing chest pain or cough. He is complaining of allergies and had congestion and sinus pain at times.

OBJECTIVE: On examination, he looks good. WT: 160. P: 96. BP: 104/64. RR: 20. Saturations on room air 94%. HEENT: He has no lesions or exudates. He has deviated septum. Lungs: He has mildly decreased breath sounds but clear. Cardiac: Regular. Abdomen: Benign. Extremities: DJD but no edema.

DIAGNOSTICS: His 6-minute walk showed his room air saturations at rest were 85%.

ASSESSMENT: He has hypoxemia, mild chronic obstructive pulmonary disease, lung carcinoma, non-small cell in the right hilum status post XRT and chemotherapy. He had staging scans again today, and he has chronic sinus disease, and this was seen on the MRI of his brain.

PLAN: We will continue his O2. We put him on Flonase. We will see him back in 4 months. We requested a copy of the scans that were done today.

Pulmonary SOAP Note Medical Transcription Sample Report #9

SUBJECTIVE: The patient is here for followup. She is having a really hard time wearing the CPAP. She knows, but she does not wear it. She has got a headache. She is tired. She wants to sleep on her stomach and it is just not seeming right. She only needs a new mask and she has not done that. We talked for a long period of time about different interventions from surgical to weight loss to repeating the study, all different kinds of options.

OBJECTIVE: WT: 200. P: 80. BP: 138/86. RR: 18. Saturations on room air 95%. HEENT: Unchanged from her last visit. She has a stage III oropharynx. Neck is supple without adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: She has obstructive sleep apnea with excessive daytime somnolence and tiredness, also some mild cognitive impairment, chronic sinusitis, and temporomandibular joint dysfunction.

PLAN: We reviewed with her surgical options, weight loss of 40 pounds, repeat PSG. She is going to think about all those. In the meantime, we will check an overnight oximetry on room air. She will check for surgeons in her area because she has moved. We will see her back in 8 weeks.

Pulmonary SOAP Note Medical Transcription Sample Report #10

SUBJECTIVE: The patient is here for followup. She is doing pretty good except she threw her back out, and she has been taking some Ultracet for that. It has been helping. She has a little bit of postnasal drip. Her breathing is otherwise unchanged. She does have a little bit of tightness at night. I reviewed her PFTs with her.

OBJECTIVE: WT: 214. P: 86. BP: 140/84. RR: 18. Saturations on room air 97%. HEENT: Unchanged from her prior visits. Neck is supple without adenopathy. Lungs: Clear. Cardiac: S1 and S2. It is irregular. Abdomen: Benign. Extremities: No edema.

ASSESSMENT: She has got mild pulmonary hypertension secondary to mitral stenosis, status post mitral valve replacement with atrial fibrillation. Her PFTs show restrictive impairment with mild asthma, which persists with a good response to bronchodilators.

PLAN: We will check yearly PFTs. I put her on albuterol MDI p.r.n. because of her chest tightness at night, told her to start with 1 puff. I will see her back in 6 months. She knows to call if there is any change in her pulmonary symptoms. I gave her some Ultracet to take as needed for her back pain. She does not want any intervention at this time because she has had that in the past.

Pulmonary SOAP Note Medical Transcription Sample Report #11

SUBJECTIVE: The patient is here for followup. He is actually doing fairly well and overall little bit improved, I think, on even the lower dose of prednisone. This is the best he has felt in a while. He has no new pulmonary complaints.

OBJECTIVE: On exam today, he looks good. WT: 196. P: 72. BP: 170/88. RR: 20. Saturations on room air 96%. With rest, his saturations are at 98%. HEENT: Unchanged from his last visit. Neck is supple. Lungs: He has a few Velcro rales at the bases. Cardiac: Regular. Abdomen: Benign. Extremities: DJD.

ASSESSMENT: He has interstitial lung disease/idiopathic pulmonary fibrosis with bronchiectasis, dyspnea, hypoxemia, and atrial fibrillation.

PLAN: Until the (XX)st of March, we are going to go with the prednisone 10 mg every other day. When he comes back, we will probably check PFTs and a CAT scan. If he gets worse or more short of breath, we told him to go up to one a day. He knows to call if there is any change in his pulmonary symptoms. We will see him back in the fall.

Pulmonary SOAP Note Medical Transcription Sample Report #12

SUBJECTIVE: The patient is here for followup of his polysomnography. He has had really no change since last visit. His wife just continues to complain that he snores quite loudly. He wakes up very frequently. He sleeps on his right side for the most part of time, and he has no other new pulmonary complaints.

OBJECTIVE: WT: 208. P: 72. BP: 126/78. RR: 18. Saturations on room air 95%. HEENT: He has no changes. He has a very small left nasal passage. It is very difficult to visualize. Oral cavity has a stage II-III oropharynx. Neck is supple. Lungs: Clear. Cardiac: Regular. Remainder of his exam is unchanged.

DIAGNOSTICS: His polysomnography showed a very mild OSA with an RDI of 5.7 with mild snoring rated at 5.

IMPRESSION: He has mild obstructive sleep apnea with a deviated nasal passage, history of coronary artery disease, peripheral vascular disease, and according to his wife, he has loud snoring with questionable witnessed apneas.

PLAN: We discussed everything with him. We actually think that he may benefit from an ENT evaluation because of his snoring. He does not really have a lot of symptoms of excessive daytime somnolence and fatigue. To that end, we put a consult into an otorhinolaryngologist who will take his insurance. We put him on some Flonase. We will see him back in 3 months.

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DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR HOSPITALIZATION:  Worsening dyspnea.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old African-American female with no prior pulmonary history, who was admitted with a one-week history of increasing breathlessness and a significant increase in these symptoms over the past one to two days.  The patient notes dyspnea with exertion, minimal activity, worsening significantly over the past several days.  This is not associated with cough, upper respiratory tract infectious symptoms, purulence, chest pain, fever, or wheeze.

PAST MEDICAL HISTORY:

1.  Hypertension.

2.  Rheumatoid arthritis.

3.  Spinal stenosis.

MEDICATIONS:

1.  Inderal.

2.  Prednisone 5 mg daily.

3.  Vasotec.

4.  KCl.

5.  Motrin.

6.  Arava.

7.  Cardizem.

No oxygen or inhalers are used at home.

ALLERGIES:  NKDA.

SOCIAL HISTORY:  The patient lives with her husband and appears to have supportive children in the area.  The patient is a nonsmoker.  The patient relates description of significant home stress in being the full-time caregiver for her husband.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Blood pressure 100/48 mmHg, pulse 62 beats per minute and regular, respirations 18 breaths per minute and nonlabored, and temperature 97.6 degrees.

GENERAL:  This is a well-developed, talkative African-American female, in no acute distress.  She has no shortness of breath noted.

HEENT:  There is no thrush appreciated.  Sclerae anicteric.

NECK:  Supple.  No nodes are found.

HEART:  Heart tones S1 and S2, RRR.  There is a small murmur heard at the sternal border.

CHEST:  Excursion is even, regular, and nonlabored.  There is no accessory muscle use.  Respirations are symmetrical.

LUNGS:  Clear breath sounds to auscultation.  There is no egophony noted.  No wheeze.  ABDOMEN:  Soft and nontender.  No hepatosplenomegaly noted.

EXTREMITIES:  Warm.  No edema.  Pulses are equal bilaterally.

LABORATORY DATA:  Oxygen saturation currently 96% on 2 liters nasal canula O2.  Chest CT, a low probability for pulmonary embolus, although tiny pericardial effusion is found.  The patient also has a 5 mm superior segment right lower lobe mass, which may be granulomatous.  D-dimer is 992, BNP 102, PT 10.6, with INR 1.0.  WBC is 8.8 with hemoglobin 12.2, hematocrit 36.8, and platelets 262,000.  Potassium 3.9, BUN 28, creatinine 1.0, and glucose 108.

IMPRESSION AND PLAN:

1.  Dyspnea.  This patient notes progressive dyspnea with activity, which has worsened over the last several days prior to admission.  Workup shows negative pulmonary origin for this dyspnea at this point; however, she will be followed closely.  Oxygen saturations with activity on room air will be assessed.  If need be, the patient may benefit from outpatient pulmonary stress testing evaluating airflow and oxygenation with simple treadmill stress.  In addition, outpatient pulmonary function testing may be considered.  Nebulized bronchodilators will be continued at this point.

2.  Hypoxemia.  Oxygen will be weaned and oxygen saturations will be assessed.  Arterial blood gas will be drawn if there are any hypoxemic events.

3.  Anxiety.  As noted in her initial history, the patient personally stated that she is under increasing familial stress and wonders if this could be related.  Social service consult will be obtained for further evaluation.

4.  Hypertension.  Blood pressure is now stable.  Stress test results from the hospital would be forwarded.

Thank you, Dr. John Doe, for the opportunity to care for your patient.

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CHIEF COMPLAINT: Pulmonary hypertension with an estimated pulmonary artery systolic pressure of 50-60 on recent echocardiogram, hypertrophic nonischemic cardiomyopathy with normal systolic function, home oxygen therapy 3 liters at rest, 4 liters with activity starting today.

SUBJECTIVE: The patient is a very pleasant (XX)-year-old woman who we see for what we thought was chronic obstructive pulmonary disease and pulmonary hypertension, which was recently diagnosed on an echocardiogram. We walked her in the hall today, and her oxygen saturation did drop down to 86% on 3 liters of home oxygen. Therefore, we have recommended that she use oxygen 3 liters at rest and 4 liters with activity.

Her chest x-ray looks like she has some congestion on it when I checked it last. We recommended that she continue her Lasix 60 mg twice daily and watch her salt intake.

Her pulmonary hypertension stems from the fact that this echocardiogram, from last month, shows an estimated pulmonary artery systolic pressure of 50-60. This was not mentioned on a previous echocardiogram from two years ago. I am wondering if she is fluid overloaded. Her BNP is over 600. Although it was better than her previous BNP, she may have elevated left-sided pulmonary venous pressures causing her pulmonary hypertension.

We discussed this with her and her family today and they are not interested in having a right-sided heart catheterization at this time. I agree.

OBJECTIVE: Blood pressure 108/62, heart rate 72, oxygen 95%. Chest is clear. Cardiac: Regular rate and rhythm.

ASSESSMENT AND PLAN:
1. Pulmonary hypertension: We will repeat her echocardiogram five months from now, and we will see her the month after.
2. Chronic obstructive pulmonary disease: Her pulmonary function test looked more restricted than obstructed. However, she does have some concavity to the expiratory limb in the flow volume curve. Her vital capacity, however, is low at 54% of predicted. I am wondering if this is secondary to congestive heart failure or if this is real restriction. Her chest x-ray does not show congestive heart failure at this time.
3. Shortness of breath with ambulation: We recommended that she take 2 inhalations of Combivent 20 minutes prior to coming to the doctor. We also recommended that she increase her ambulatory oxygen to 4 liters and use 3 liters at rest.

We will see her back in six months. We will get an echocardiogram in five months and discuss the results of this. When I see her back, she will get a walking oximetry test and pulmonary function test.

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DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:

1. Hemoptysis.

2. Right lung mass.

POSTOPERATIVE DIAGNOSES: Not given.

PROCEDURE PERFORMED: Bronchoscopy with brushing and biopsy.

DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient. Procedure and the complications including complication of anesthesia, pneumothorax requiring chest tube, bleeding complication, arrhythmia, hypoxia, need for ventilation was explained to the patient and he consented for the procedure.

The patient was brought to the operating suite. Under general anesthesia, endotracheal tube was placed by anesthesiologist. Bronchoscopy was done through endotracheal tube. Distal trachea is normal. Main carina is sharp. Bronchoscope was advanced to the left lung. Left upper lingula and lower lobe were visualized up to subsegmental level. All subsegments are patent. No endobronchial or mucosal lesions were seen.

The bronchoscope was further advanced to the right lung. Right upper, middle and lower lobe were visualized. All subsegments are patent. No endobronchial obstructing or mucosal lesions were seen. Right lower lobe bronchoalveolar lavage and brushing was done. It was sent for cytology. Right upper lobe bronchoalveolar lavage, brushing and biopsies were done. Biopsies sent for pathology. Bronchoalveolar lavage sent for cytology. Brushing sent for cytology. The patient tolerated the procedure well. Postprocedure chest x-ray to rule out pneumothorax.

Bronchoscopy Operative Transcription Sample Report #2

DATE OF OPERATION: MM/DD/YYYY

OPERATION PERFORMED:

1. Fiberoptic bronchoscopy.

2. Cervical mediastinotomy with frozen section.

3. Video-assisted thoracoscopic surgery, right lower lobe resection.

4. Mediastinal lymphadenectomy.

SURGEON: John Doe, MD

DESCRIPTION OF PROCEDURE: With the patient in the supine position on the operating room table, after the induction of double-lumen endotracheal anesthesia, fiberoptic bronchoscopy down to the subsegmental level was performed. There was no evidence of endobronchial pathology. Cervical mediastinotomy with frozen section biopsy was then performed via routine technique and the frozen section report was negative for metastatic carcinoma to the N2 nodes.

We then positioned the patient right side up and prepped and draped for a posterolateral thoracotomy. A couple of ports were introduced to the 5th and 7th intercostal spaces; unfortunately, we did not have good single lung isolation, and this complicated the performance of the procedure quite greatly. We did begin performing the right lower lobectomy by starting with a mini thoracotomy incision measuring perhaps 6 to 8 cm in size in the 5th intercostal space. Soft tissue retractor was positioned, and we started and had good exposure.

We then mobilized the inferior pulmonary ligament and performed mediastinal lymph node dissection. We could initially not see the mass very easily, partially because of the lung not being well deflated. We did mobilize and divide the inferior pulmonary vein and divided this with a vascular Endo GIA stapler and then we also identified the pulmonary arterial supply to the lower lobe, which was in the fissure and divided this with the vascular stapler. We completed the remainder of the resection with the Endo GIA 45 EZ stapling device. At this point, lymph node sampling was performed throughout the mediastinum and represented samples are included in the pathology report.

Unfortunately, upon removing the specimen, we could not find any evidence of the tumor still within the pathology. We did examine within the chest and found that there was a mass really adherent to the ribs at T6-T7, so that we had to perform a limited chest wall resection. This was biopsied intraoperatively and found to be consistent with a schwannoma. This was probably at the T6 nerve root. We did perform intraoperative consultation with a neurosurgeon who, as noted previously, did perform intraoperative consultation.

We performed resection of T6-T7 in its entirety, and there was some erosion of this schwannoma into the rib space. We had a small amount of dural leaking, so we used CoSeal to form a dural patch and secured hemostasis. We then placed a single chest tube and closed the chest using #1 Tevdek repair across the suture, running 0 Maxon, running 2-0 Vicryl, running 3-0 Vicryl. Steri-Strips and sterile dressing were applied to the wounds. The patient tolerated the procedure well and was brought to the recovery room in satisfactory condition.

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acute respiratory distress syndrome (ARDS)

aerosol therapy

air trapping

airflow

airflow obstruction

alveolar volume

anosmia

aphonia

arterial blood gas (ABG)

asbestosis

aspiration pneumonia

assist-controlled mechanical ventilation (ACMV)

AutoPap

BiPAP

bronchial washings

bronchiogenic

bronchodilator therapy

bronchoscopy

bronchospasm

chronic obstructive pulmonary disease (COPD)

CO2

CPAP (continuous positive airway pressure)

CPAP titration level was _____ cm of water

daytime somnolence

diffusing capacity

DLCO (diffusing capacity of lung for carbon monoxide)

dyspnea on exertion

emphysema

empyema

endotracheal intubation

Epworth sleepiness scale

ethmoid sinuses

exercise-induced asthma

FEF (forced expiratory flow)

FEF25-75%

FEV1

FEV1/FVC

fiberoptic bronchoscopy

FiO2

flow volume loop

FRC (functional residual capacity)

frontal sinuses

FVC

ground-glass appearance

ground-glass opacification

hand-held nebulizer

hemoptysis

hypercapnia

hyperinflation

hyperpnea

hypoxemia

hypoxia

ILD (interstitial lung disease)

incentive spirometry

inhaled corticosteroid

IPF (interstitial pulmonary fibrosis)

IPPV (intermittent positive pressure ventilation)

lingula

maxillary sinuses

maximum voluntary ventilation

MDI (metered-dose inhaler)

MVV (maximum voluntary ventilation)

nocturnal polysomnography

nonrebreathing mask

O2

obstructive defect

obstructive impairment

obstructive lung disease

orthopnea

OSA (obstructive sleep apnea)

overnight oximetry

parenchyma

parenchymal

PCO2

PEEP (positive end-expiratory pressure)

PFTs (pulmonary function tests)

PND (paroxysmal nocturnal dyspnea)

Pneumocystis carinii

Pneumovax

PO2

polysomnography

PPD (tuberculosis test)

PSG (polysomnography)

pulmonary artery wedge pressure

pulmonary capillary wedge pressure

pulmonary hypertension

rebreathing mask

restrictive impairment

saturations on room air

sawtooth pattern

Shiley tracheostomy tube

silicosis

sleep disordered breathing

somnolence

spirometry

steroids with taper

three-pillow orthopnea

tidal volume

TLC (total lung capacity)

TLV (total lung volume)

tracheostomy cuff

tracheostomy stoma

two-pillow orthopnea

updraft treatment

Venti mask

ventilation/perfusion (V/Q) scan

Wegener granulomatosis

witnessed apneas

work of breathing (e.g., increased work of breathing)

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Pulmonary Medical Transcription Operative Sample Report #1

OPERATIONS PERFORMED:
1. Flexible bronchoscopy.
2. Right muscle-sparing lateral thoracotomy with complete decortication of the lung with drainage of right lower lobe lung abscess.

DESCRIPTION OF OPERATION: The patient was brought to the operative suite, placed in the supine position. After satisfactory induction of general endotracheal anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal tube, visualizing the distal trachea, carina, right and left main stem bronchus with primary and secondary divisions. No evidence of any endobronchial tumor was noted. What I did see was some crowding involving the right middle lobe and right lower lobe bronchi. The scope was then withdrawn.

A double-lumen endotracheal tube was then positioned by the anesthesiologist. The patient was placed in the left lateral decubitus position and prepped and draped in the usual sterile fashion. A right muscle-sparing lateral thoracotomy was made. We entered via the fifth intercostal space. Careful exploration was carried out and findings were as stated above. The gelatinous material present in the right pleural space was completely evacuated. Adhesiolysis was carried out freeing up the entire right lung.

Decortication was next carried out, being careful not to injure the underlying lung parenchyma. The patient had a very thick pleural rind. While performing the decortication, I unroofed a 2 x 2 cm right lower lobe lung abscess. The contents were evacuated. I sent cultures of the abscess cavity as well as of the empyema cavity in separate containers to microbiology for examination. All decorticated tissue was also sent to pathology for examination as well. Excellent lung expansion was noted. I irrigated the entire region using several liters of warm antibiotic saline solution until the effluent came back clear and then I irrigated with several more liters.

Attention was then directed at closing. Two 32-French chest tubes were placed, 1 anteriorly and 1 posteriorly, and these were brought out through inferior stab wounds. The ribs were approximated using heavy Vicryl sutures. The chest wall muscles, fascia, skin and subcutaneous tissues were approximated using the same suture material. Dressings were applied. Marcaine 0.25% was used as a paravertebral/interfacet block at the level of T2 to T9. The patient tolerated the procedure well and was sent to the intensive care unit in stable condition.

Pulmonary Medical Transcription Operative Sample Report #2

OPERATIONS:
1. Flexible bronchoscopy.
2. Cervical mediastinoscopy with biopsy and thyroid isthmusectomy.

PROCEDURE IN DETAIL: The patient was brought to the operative suite and placed in supine position. After satisfactory induction of general endotracheal anesthesia, a flexible Olympus bronchoscope was passed through the endotracheal tube visualizing the distal trachea, carina, right and left main stem bronchus of the primary and secondary divisions. No evidence of any endobronchial tumor was noted. The scope was then withdrawn. The patient was then prepped and draped in the usual sterile fashion. A shoulder roll was placed. A curvilinear incision was made above the suprasternal notch in the line of a skin crease. Dissection was carried down through the subcutaneous tissue down through the platysma muscle. The strap muscles were next identified and laterally retracted. We continued our dissection down to the pretracheal space. A thyroid isthmusectomy was done without any problems; this gave me clear access to the pretracheal space. A pretracheal plane was next developed. A mediastinoscope was placed. I saw multiple, firm right paratracheal lymph nodes. After first aspirating these structures to make sure they are not vascular in nature, generous biopsies were taken and sent to pathology for examination. Frozen section analysis revealed these to be consistent with lymphoma. Excellent hemostasis was obtained. The wound was irrigated using warm antibiotic saline solution. The wound was then closed in layers using Vicryl sutures. Dressings were applied. Marcaine 0.25% was used as a regional block. The patient tolerated the procedure and was sent to the recovery room in stable condition.

Pulmonary Medical Transcription Operative Sample Report #3

PREOPERATIVE DIAGNOSIS: Respiratory insufficiency.

POSTOPERATIVE DIAGNOSIS: Respiratory insufficiency.

OPERATION: Tracheotomy with division of thyroid isthmus.

ESTIMATED BLOOD LOSS: Less than 10 mL.

FLUIDS: Crystalloid.

COMPLICATIONS: None.

TECHNIQUE: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck.

A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed and then the strap muscles separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly-based tracheotomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin.

Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. The trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition.

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